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Please complete this form and return it with any required attachments to the Project Coordinator. No activities related to this project may be conducted beyond the current approved expiration until
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Doc DHSS Use Only refers to a document specifically utilized by the Department of Health and Social Services for administrative purposes.
Entities or individuals specified by the Department of Health and Social Services must file the doc DHSS Use Only.
To fill out the doc DHSS Use Only, follow the instructions provided by the Department of Health and Social Services, ensuring all required fields are completed accurately.
The purpose of doc DHSS Use Only is to collect necessary data for regulatory compliance and program administration.
Information that must be reported includes identification details, compliance data, and any other relevant information as specified by the Department.
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